Return to Play – A Personal Perspective

Return to Play – A Personal Perspective
Peter Brukner, MBBS, FACSP
eturn to play issues are at the heart of sports medicine and frequently present significant
challenges to the sports physician. In their editorial which appears elsewhere in this
volume, Best and Brolinson provide an excellent overview of the general issues relating to
return to play. Whereas theirs is a North American perspective, the issues are universal and
can be as troubling to a middle-aged Australian physician caring for a variety of athletes and
teams in an array of settings as they are to those practicing in a highly charged, performanceoriented US college or professional sport environment. Sleepless nights can be the lot of
physicians in many parts of the globe!
Concussion has always been a source of controversy. Many of us grew up playing, and
then practicing, in the era of mandatory rest periods following a concussion. I remember
being concussed one weekend and being prevented from playing the following week despite
being totally asymptomatic all week. In my early days as a team doctor in professional
football (one of the many Australian varieties!), I remember insisting that a concussed
player stand out a week when the coach, the player and I, although not admitting it at the
time, knew that the player was fully recovered. During that era interest was growing in
neuropsychological testing as a more objective measure of recovery from concussion, Over
the past two decades of pen-and-paper, and more recently, computer-based neuropsychological testing, we have come to understand that clinical assessment of recovery
parallels the neuropsychological tests.
We have moved away from mandatory recovery periods and now treat each individual
case on its merits. We know that when our patients are totally asymptomatic then they are
ready to resume light activity and, in the absence of symptoms associated with graduated
increases in activity, can return to contact sport. The Vienna and Prague guidelines have
given physicians excellent frameworks for decision making.1,2 I don’t lie awake at night over
concussion any more!
Muscle strains, in particular hamstring strains, have also been known to cause me
disordered sleep! Hamstring strains occur frequently and have a high recurrence rate. The
timing of return to play for an athlete with such an injury, professional or otherwise, who is
desperate to return to play in the shortest possible time, is a difficult dilemma. It is a matter
of striking a balance between rapid return to play and the risk of recurrence. At what stage
does that risk become acceptable? There are many factors which may affect that decision.
Do we have objective approaches that will guide our decisions?
Previously we relied heavily on isokinetic strength testing with mandatory strength
requirements eg, strength level that is 95% of the uninjured leg being a prerequisite for
return to sport.3 More recently some have advocated the use of the appearance on MRI as
a major determining factor with the size of the lesion and its location (biceps femoris strains
appear to take longer to recover) being the important factors.4 Others recommend functional
field testing which is not without associated risks.5 Probably some combination of these
methods is ideal. Alternatively we could heed the words of a wise old football coach who
once said ‘‘wait until the hamstring seems 100% - then wait another week!’’
The final return to play issue I would like to address is, I believe, one of the most
important issues in sports medicine today. It relates not to the timing of return to play, but
whether sportspeople after sustaining significant injuries to weightbearing joints should
return to play at all.
Prior to the 1970s an athlete sustaining an ACL rupture in a pivoting sport would in all
likelihood have retired as there was no appropriate treatment available. ACL reconstruction
From the Sports Medicine Centre for Health, Exercise and Sports Medicine University of Melbourne, Australia.
Reprints: Peter Brukner, Exercise and Sports Medicine University of Melbourne 3010, Australia (e-mail: [email protected]).
Copyright Ó 2005 by Lippincott Williams & Wilkins
Clin J Sport Med Volume 15, Number 6, November 2005
has enabled most of those sustaining this injury to resume their
sport after an interval of 4–12 months.
Unfortunately there are nearly always other structures
damaged when the ACL is torn. The high incidence of meniscal
injuries is well documented and since the advent of MRI we
have become aware of the frequency of bone bruising as well as
the more obvious articular cartilage defects.6 As a result of these
accompanying injuries, degenerative change is an almost inevitable consequence of an ACL rupture. Initially it was hoped
that reconstruction of the ACL would reduce the incidence or
severity of osteoarthritis (OA) by providing increased stability,
but it would appear that reconstruction does not affect the incidence of OA.7,8 The question that those of us dealing with
these injuries must ask is whether our skill in reconstructing the
ligament and rehabilitating the athlete to his or her pre-injury
state to enable return to play is actually accelerating the development of OA?
Prospective studies need to be performed to answer that
question, but in the meantime is it our duty to inform patients
with ACL rupture (and this may also be relevant for severe
ankle sprains with talar dome damage as well as other similar
conditions) of the potential risk of accelerating development of
OA? It may be that after receiving that information the athlete,
particularly the elite or professional competitor, will still
decide to return to play. Those for whom sport is not their
livelihood may opt to retire and take up a non weight-bearing
form of activity. But it is our responsibility to contextualize
their injury, and its potential sequelae, in an understandable
and relevant way. At present we encounter too many recently
Clin J Sport Med Volume 15, Number 6, November 2005
retired sportspeople bemoaning the fact that they can’t jog or
kick a football with their children and lining up for joint
replacement surgery only to be told that they will have to wait
because they are too young! It is an issue that we as
a profession must address.
Decisions regarding return-to-play have never been easy.
Rigorous, evidence–based criteria for return-to-play decisions
were not a feature of the past. They will, hopefully, become
a part of our future.
1. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of
the first International Conference on Concussion in Sport, Vienna 2001. Br
J Sports Med. 2002;36(1):6–7.
2. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement
statement of the 2nd International Conference on Concussion in Sport,
Prague 2004. Br J Sports Med. 2005;39:i78–i86.
3. Heiser T, Weber J, Sullivan G, et al. Prophylaxis and management of hamstring muscle injuries in intercollegiate football players. Am J Sports Med.
4. Connell DA, Schneider-Kolsky ME, Hoving JL, et al. Longitudinal study
comparing sonographic and MRI assessments of acute and healing
hamstring injuries. AJR Am J Roentgenol. 2004;183:975–984.
5. Brukner PD, Khan KM. Clinical Sports Medicine. Revised second ed.
Sydney: McGraw Hill; 2002.
6. Bretlau T, Tuxoe J, Larsen L, et al. Bone bruise in the acutely injured knee.
Knee Surg Sports Traumatol Arthrosc. 2002;10:96–101.
7. Lohmander LS, Ostenberg A, Englund M, et al. High prevalence of knee
osteoarthritis, pain, and functional limitations in female soccer players
twelve years after anterior cruciate ligament injury. Arthritis Rheum.
8. Feller JA. Anterior cruciate ligament rupture: is osteoarthritis inevitable?
Br J Sports Med. 2004;38:383–384.
q 2005 Lippincott Williams & Wilkins